Authors:

Fabrizio Di Benedetto MD PhD FACS, Paolo Magistri MD

Hepato-pancreato-biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy

Summary:

This is the case of a 67 years-old man affected by chronic HBV-related liver cirrhosis who was diagnosed with a large hepatocellular carcinoma (HCC) of the left lobe, AFP negative. On CT-scan the lesion was suspect for diaphragmatic infiltration and resulted to be close to the left portal vein. After multidisciplinary evaluation in our Institutional tumor board the patient was scheduled for left hepatectomy with robotic approach. On exploratory laparoscopy there was no diaphragmatic infiltration, therefore the procedure was carried on as planned.

Robotic approach for HCC on cirrhosis is particularly effective to reduce the risk of liver decompensation and improve post-operative outcomes, with lesser incidence of morbidity, shorter in-hospital stay and early return to daily life activity. Moreover, oncological long-term results are comparable to open and laparoscopic series published so far1-2. Major hepatectomies can also be safely performed robotically in selected cirrhotic patients when a comprehensive learning curve has been completed3.

The post-operative course was uneventful, and the patient was discharged in good general conditions on post-operative day 4. The final pathology confirmed the diagnosis of a large HCC (8 cm), with negative resection margins. One year later, the patient underwent liver transplantation (LT) with ab-initio indication (no signs of recurrence) and currently, 18 months after LT, he is still in follow-up in good general conditions and without signs of recurrence. In our experience robotic liver resection represents an optimal tool for down-staging and bridging to liver transplantation thanks to the reduced risk of decompensation and infection, and fewer adhesions have been reported in our series4.

1. Di Benedetto F, Petrowsky H, Magistri P, Halazun KJ. Robotic liver resection: Hurdles and beyond. Int J Surg. 2020 Oct;82S:155-162. doi: 10.1016/j.ijsu.2020.05.070. Epub 2020 Jun 3. PMID: 32504813.
2. Magistri P, Tarantino G, Assirati G, Olivieri T, Catellani B, Guerrini GP, Ballarin R, Di Benedetto F. Robotic liver resection for hepatocellular carcinoma: A systematic review. Int J Med Robot. 2019 Aug;15(4):e2004. doi: 10.1002/rcs.2004. Epub 2019 May 28. PMID: 31039281.
3. Magistri P, Assirati G, Ballarin R, Di Sandro S, Di Benedetto F. Major robotic hepatectomies: technical considerations. Updates Surg. 2021 Jan 7. doi: 10.1007/s13304-020-00940-1. Epub ahead of print. PMID: 33411220.
4. Magistri P, Olivieri T, Assirati G, Guerrini GP, Ballarin R, Tarantino G, Di Benedetto F. Robotic Liver Resection Expands the Opportunities of Bridging Before Liver Transplantation. Liver Transpl. 2019 Jul;25(7):1110-1112. doi: 10.1002/lt.25477. Epub 2019 May 21. PMID: 31021039.